Why Are So Many Doctors Misdiagnosing and Overtreating Ear Infections?

Last March, while on vacation in Florida, my 11-month-old came down with a fever. We took him to a local pediatrician who quickly diagnosed him with a middle ear infection and prescribed him a 10-day course of antibiotics. Two days later, back home in New York, our pediatrician said our son probably never had an ear infection, and that regardless, he should stop taking the drugs.

At the time, I was exceptionally annoyed—goddamn podunk doctor. What irked me wasn’t just the misdiagnosis; it was that he had recommended unnecessary drugs that may have upset my baby’s stomach and potentially, research suggests, increased his risk for asthma and irritable bowel disease. But it turns out Dr. Florida’s actions were less the exception than the rule: Many U.S. pediatricians overdiagnose and overtreat ear infections, in part because of how difficult it is to accurately perform ear exams and in part because doctors feel you breathing down their stethoscope-adorned necks for the meds.

To make things even more complicated, the microbes that cause ear infections are changing: Vaccines have shifted the microbial flora blooming in American children, and thanks in part to routine antibiotic overuse, some bugs have become much harder to treat.

Common in the wintertime, middle ear infections—technically called acute otitis media, not to be confused with outer ear infections (swimmer’s ear) or rare inner ear infections—aren’t a big deal. Nearly 80 percent of American kids have had one by the time they turn 3; many seem to battle them constantly—perhaps yours? No one knows why some kids are more prone to them than others, but some research suggests that genetics plays a role, and environmental factors such as day care, exposure to tobacco smoke, and formula feeding are known to boost the risk as well. Ear infections can, however, be more than just a painful, oozing nuisance: They sometimes cause fluid to build up in the middle ear, leading to long-term hearing loss and language and literacy problems (and maybe even picky eating, as I discussed in my last column). Serious infections, left untreated, can also cause meningitis or mastoiditis, an infection of the mastoid bone in the skull, which requires surgery.

So, no, ear infections should not just be ignored. But a 2008 French study reported that one-fifth of ear infections diagnosed by general practitioners are in reality something else, like minor ear inflammation; 7 percent of the time, doctors deem perfectly healthy ears infected. Why is ear health such a medical mystery? Fevers, ear pulling, and ear pain don’t necessarily predict the presence of an infection, so doctors have to examine the middle ear to be sure—and that’s really hard to do to a sick child. Doctors typically have to insert an instrument into the kid’s ear, establish an airtight seal, squeeze a rubber bulb to release several bursts of air, and then watch to see how the child’s eardrum responds. Oh, and if there’s any earwax, the doc has to pluck it out with tweezers and try the whole thing again. As you can imagine, this doesn’t always go well, so many pediatricians end up just peering into your kid’s ear, seeing a little redness and guessing at a diagnosis instead.

Even if a doctor is certain of an infection, there’s the problem of knowing what kind of ear infection it is. Some are caused by viruses, which are immune to antibiotics, whereas others arise because a respiratory virus like the cold or flu made it easier for pre-existing bacteria to grow in the middle ear canal. (During a cold, mucus can block one or both Eustachian tubes, creating negative pressure inside the middle ear that pulls nearby bacteria in; at the same time, the plugged tube stops draining middle ear secretions into the throat, so the moisture-loving bacteria overgrow.) The only way a doctor can tell an infection’s microbial origin is by inserting a needle into a child’s eardrum and aspirating out some of the middle ear fluid, which (thankfully) few doctors do.

Problem is, without knowing what’s causing an infection, it’s very difficult to know how best to treat it. Since 2004, the American Academy of Pediatrics has advised doctors against giving antibiotics to kids over the age of 2 if their ear infections are not severe. (All children under 6 months should get antibiotics, and kids between 6 months and 2 years should get them only if the doctor is absolutely certain of the infection, which is apparently only half the time.) Under this “watchful waiting” approach, doctors are supposed to re-examine the child a few days later to see if the infection is getting better; if it’s not, drugs then might be in order. (The AAP is expected to release new treatment guidelines sometime this year.)

There’s a good reason for this conservative approach: No matter what their cause, most ear infections go away on their own. In a 2011 clinical trial, University of Pittsburgh researchers reported that 74 percent of children under 2 who were suffering from ear infections got better after one week when they weren’t given any treatment; 80 percent of those who got antibiotics got better in the same time frame. Yet half of the kids treated with antibiotics in the study got bouts of diarrhea, compared with only 27 percent of the kids who didn’t take anything. (Ear tubes, which are sometimes surgically inserted in children who have recurring infections, can help but research suggests for only about six months.) So, yes, after a week on amoxicillin your son finally stopped wailing, waking in the night, and tugging at his ear. But that could very well have been just because time had passed and his immune system fought the bug off.

Unfortunately, most doctors prescribe antibiotics anyway. In a 2010 study, Boston University researchers surveyed 300 pediatricians and found that 85 percent of the time, when infections were minor, doctors ignored the AAP’s guidelines and prescribed drugs. Most of the doctors said they thought that the guidelines made good sense, but they felt pressured by parents to give out drugs anyway. This reckless overuse of antibiotics isn’t just expensive; it is believed to drive antibiotic resistance, too. In 2007, scientists at the U.S. Centers for Disease Control and Prevention identified a new form of Streptococcus pneumoniae called 19A that causes childhood ear infections and is resistant to every FDA-approved antibiotic. Now that’s a bug you don’t want your child to get.

Ear infections are changing in other ways, too. In 2000, a vaccine called PCV7, which protects kids against seven (out of a total of 93) subtypes of Streptococcus pneumoniae, became part of the standard U.S. vaccine schedule; in 2010, it was replaced with PVC13, which protects against five additional subtypes, including the drug-resistant 19A. As a result of these vaccines, overall ear infection numbers have dropped by 6 percent since 2000, but the types have now shifted in that more infections are now caused by Haemophilus influenzae or Moraxella catarrhalis than they used to be. Doctors disagree about what these changes mean, clinically speaking: On the one hand, the new vaccine protects against 19A and should therefore reduce the number of resistant 19A infections, but on the other hand, some strains of the now more common H. influenzae do not respond to first-line antibiotics.

The bottom line is that ear infections are beguiling, yet they are also less common than you might have been led to believe and more innocuous as well. This doesn’t mean you shouldn’t take your shrieking, ear-clawing child to the pediatrician. You should. But don’t pitch a fit while you’re there—what do you mean you’re not giving Lola antibiotics? She’s been screaming for 17 hours!—and if your doctor prescribes drugs without skipping a beat, consider asking if a watchful waiting approach might work instead. Then, pick up some pain relievers on the way home— a bottle of children’s Tylenol for her, and some chardonnay for you.

The Kids would like to thank Melinda Pettigrew at Yale University, Tumaini Coker at UCLA, and Itzhak Brook at Georgetown University.